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Malignant Melanoma Management and Long-Term Follow-Up in Five Feet

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Malignant Melanoma Management and Long-Term Follow-Up in Five Feet CHAPTER 20 Malignant Melanoma Management and Long-Term Follow-Up in Five Feet Pamela Hong, DPM George Rivello, DPM Donald Green, DPM INTRODUCTION Plantar melanoma excision sites are not usually closed primarily. The wounds are allowed to granulate and once Melanoma is the most common malignancy of the foot and primary healing has taken place, the use of skin grafts and ankle (1). Melanoma of the foot and ankle is more likely to flaps are usually done to restore weight-bearing function. be misdiagnosed or diagnosed later than melanoma of other Thus, collaborative of care of various medical professionals anatomic sites, and accounts for 3-15% of all cutaneous including plastic or general surgery and oncology are melanomas (1-2). A malignant lesion is often misdiagnosed necessary to improve the outcome of patients. for a nonhealing ulcer, subungal hematoma, verruca, or Currently, sentinel lymph node biopsy is considered the fungal nail changes (3-4). Patients do not readily notice a standard for evaluating lymph node involvement. Lymphatic lesion of the foot or ankle if it is not painful and especially mapping via lymphosyntigraphy and intraoperative injection if the location is on the sole of the foot. By the time the of blue dye or radioisotope is used to identify the first melanoma is correctly diagnosed, the tumors are usually (sentinel) lymph node immediately downstream from the thicker and at a more advanced stage resulting in poorer primary tumor (12). For lesions that are more than 1 mm prognosis. It is thus paramount to be suspicious of lesions thick, a sentinel lymph node biopsy is recommended (13). early and to make an accurate diagnosis and treatment plan For melanomas that are 0.75-1 mm thick with adverse to improve the rate of survival for patients affected by this characteristics such as lymphovascular invasion, ulceration, aggressive cutaneous neoplasm. increased mitotic rate, significant vertical growth phase, In order to help reduce the overall mortality, performing and with positive margins, a sentinel lymph node biopsy a biopsy is a crucial step in the management of malignant should be considered (14). The literature recommends that melanoma. Guidelines suggest that excisional biopsy is the a complete lymph node dissection should be done if there recommended procedure for suspected malignant melanoma is a positive sentinel lymph node biopsy (15). Additionally, as it allows for diagnosis, proper depth and staging of the adjuvant interferon alpha is recommended for patients who tumor, as well as treatment and prognosis (5). Punch biopsies have a greater than 10-year life expectancy. continue to be used by many physicians even though it is not In this report, we describe a case series of the surgical usually the procedure of choice (6). Incisional biopsies have management and long-term follow-up results for melanoma been reported to be less appropriate as the lesion is likely in the foot and ankle of 5 patients. We attempted to evaluate to be inadequately excised with residual tumor remaining at the distinguishing features of melanoma of the foot. Each both the radial and deep margins. Since only the superficial melanoma was classified according to its site on the foot, portion of the tumor is removed, this results in an inaccurate the treatment strategies, complications, and minimum estimation of tumor thickness, which is a key prognostic 12-month follow-up were investigated. Our case series factor and treatment determinant (7). However, because it may serve as a reference point for determining treatment is quick and less invasive, this is a common procedure done strategies in the future. in office to confirm any suspicious lesion. Once melanoma is confirmed, definitive surgical METHODS treatment is wide local excision (8). The recommended margin of normal tissue to be resected is based on the Between 2013 and 2016, 5 patients who had primary thickness of the melanoma (9). For melanomas <1 mm thick, cutaneous melanoma in the foot or ankle were seen at the a 1 cm margin is recommended. For lesions that are 1-2 mm Kaiser Permanente South Sacramento Podiatry Clinic. These thick, a 2 cm margin of normal tissue is recommended, and 5 patients received their treatment by the same podiatric for lesions that are 2-4 mm or >4 mm, a 2 cm margin is also surgeon at Kaiser. A retrospective analysis and evaluation recommended (10). There has been no evidence supporting review of these 5 patients were done. The hospital records margins >2 cm to decrease the incidence of local recurrence were reviewed with attention paid to the basic demographics, or improve survival rate (11). 90 CHAPTER 20 the site of involvement, depth and stage of the lesion, whether Case 1 was a 59-year-old white woman who presented there had been a delay in diagnosis, surgical management with a plantar first metatarsal head ulcer that was present of the lesion, additional procedures, sentinel lymph node for 3 years. It was noted to be ulcerating and bleeding for biopsy results, and 12-month follow-up. 1 month. A punch biopsy was done prior to ultimate wide The standard treatment plan for malignant melanoma excision with 2 cm margins and right inguinal sentinel was wide local excision and reconstruction with sentinel lymph node biopsy, negative margins and negative sentinel lymph node biopsy. We adopted wide local excision margins lymph node biopsy. The patient’s wound was completely depending on the Breslow thickness. The surgical margin healed at 5 months postoperative (Figure 1). was 0.5 cm for in situ melanoma, 1 cm for lesions ≤1 mm in depth, 2 cm for lesions 1.01-2.0 mm in depth, and 3 cm for lesions >2.0 mm in depth. Lesions on or near the toe occurred in 1 of our patients and was treated with amputation of the toe. One lesion that was located on the posterior heel required a split-thickness skin graft. All other foot lesions were treated with wide excisions followed by wound VAC therapy for secondary intention skin closures. Sentinel lymph node biopsy was performed therapeutically in all 5 patients by a general surgeon at the same institution. RESULTS There were 5 patients who underwent both the initial biopsy and the surgical treatment for melanoma in the foot from Figure 1A. Clinical image of lesion when patient first noticed it 3 years ago. 2013-2016 at this single institution. These 5 patients also underwent a sentinel lymph node biopsy. Of the 5 patients, 3 were female and 2 were male, and 3 were white and 2 were Asian (1 Hmong and 1 Vietnamese). The mean age at the time of presentation was 59.6 years (range 38-80 years). The plantar aspect of the foot was the common site of involvement, found in 4 of the 5 patients, and only 1 lesion was found on the posterior heel. The Breslow thickness classification (in situ, ≤1 mm, 1.01–2 mm, 2.01-4 mm, >4 mm) was used to determine the depth of invasion. Measured in millimeters, an ocular micrometer was used to measure lesions from the granular layer in the epidermis to the deepest vertical part invasion. The depth of invasion has been known to be the single most prognostic factor in melanoma (Table 1). Figure 1B. Appearance after punch biopsy during presentation of worsening skin lesion. Table 1. Results of case series* Pt Age Sex PMHx Race Breslow STSG SLNB Lesion Mean follow-up, thickness, mm months 1 59 F None White 2.3 No Neg Plantar foot 33 2 54 M None Vietnamese 8.5 No Neg Plantar foot 5† 3 38 F Hep B Hmong 3.2 No Neg Plantar foot 20 4 67 F MM Black 1.05 Yes Neg Posterior heel 13 5 80 M DM2 White 1.8 No Neg Plantar foot 6 *Age = at time of surgery; STSG = split-thickness skin graft; SLNB = sentinel lymph node biopsy; MM = multiple myeloma. † Patient lost to follow-up. After wide excision with negative margins, the patient’s wound completely healed via negative pressure wound therapy and secondary intention. CHAPTER 20 91 Case 2 was a 54-year-old Vietnamese man who Case 3 is a 38-year-old Hmong woman who presented presented with a painless plantar first metatarsal head ulcer. with a plantar heal ulcer that had been present for 10 years. A shave biopsy was done prior to ultimate left foot wide A punch biopsy was done before an ultimate right foot wide excision with 1.5 cm margins with negative pressure wound excision with 2 cm margins and right inguinal sentinel lymph therapy and left axillary sentinel lymph node biopsy; both node biosy, both of which were negative. At 4 months, the of which were negative. The patient’s wound completely patient’s wound is healed (Figure 3). healed at 3.5 months (Figure 2). Figure 2A. Plantar first metatarsal melanoma lesion Figure 2B. View 3 weeks after wide excision of at presentation. lesion and NPWT. Figure 2C. Appearance 3 months after wide excision Figure 3A. Plantar heel melanoma upon of lesion and NPWT. presentation. 92 CHAPTER 20 Case 4 is a 67-year-old black woman who presented healed (Figure 4). with a right posterior heel ulcer that has been present for Case 5 is an 80-year-old white man who presented with years. A shave biopsy was done before an ultimate right a plantar fifth metatarsal head melanoma lesion that had heel wide excision with 2 cm margins and right inguinal been present for many months. A shave biopsy was done sentinel lymph node biopsy, both of which were negative. before an ultimate right foot partial fifth ray amputation and The patient also underwent a split-thickness skin graft over right inguinal sentinel lymph node biopsy, both of which the surgical site as it is a nonweight-bearing surface.
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